The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Psychotherapist burnout affects patient outcomes
Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.
Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.
This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.
The Emotionally Burdened Psychotherapist
Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice. Advance online publication.
To provide good treatment, a psychotherapist must have enough mental and emotional energy to be attuned to the different states of their patients. However, sometimes emotional reserves of therapists can dwindle because of personal or professional burdens. As a result, many therapists report the experience of burnout that inevitably has a negative effect on their patients. Therapists’ personal burdens can be defined as stress in one’s personal life, feeling worry or concern, experiencing conflict within one’s family, or loss of a loved one. These therapist personal burdens could be enduring vulnerabilities or short-lived stressors, but they nevertheless have an impact on the therapist’s effectiveness. Higher stress in a therapist’s personal life is related to more avoidant coping, and lower capacity to stay focused, engaged, and empathic with patients. In this large-scale survey of over 12,000 psychotherapists worldwide (e.g., Norway, US, Canada, UK, Australia, Denmark, China), Nissen-Lie and colleagues looked to identify past and current personal and situational factors that were linked to the experience of personal burden among psychotherapists. The therapists were mostly married or in a committed relationship (72%), half were psychologists, the average length of clinical practice was 12 years (SD = 9.2), and therapists worked almost evenly across the major theoretical orientations (including CBT, psychodynamic, systemic, and behavioral). The most salient predictors of personal burden among psychotherapists were: current health and financial worries, early trauma or abuse, attachment anxiety (i.e., concern about abandonment and difficulty regulating negative emotions), dominant and demanding behavior in relationships, lower work satisfaction, and younger age. Cumulatively, these variables accounted for a substantial amount (30%) of the variance in personal burden.
Increasingly, research is pointing to negative life events and work experiences that may limit a therapists’ capacity to be engaged and empathic with patients. Focus on therapist well-being should be an important part of clinical training and supervision. Previous research found that receiving personal therapy, obtaining clinical supervision, working shorter hours, and lower caseloads improved empathy and wellbeing among psychotherapists.
Does Clinical Training Lead to Greater Therapist Interpersonal Skills?
Wolfer, C., Visla, A., Held, J., Hilpert, P., & Fluckiger, C. (2021). Assessing interpersonal skills—A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills. Clinical Psychology and Psychotherapy, 28, 226-232.
Differences between therapists may account for 2% to 8% of the variance in patient mental health outcomes. This seems like a small amount, but the effect is as large as the specific effects caused by interventions of any therapeutic orientation. One of the factors that accounts for differences between therapists is therapist interpersonal skills such as empathy, respectfulness, warmth, openness, and willingness to collaborate. These skills can be learned and likely allow some individuals to be more effective when encountering challenging or complex interpersonal situations. One might think that such skills would be a pre-requisite for entering psychotherapy training, but that may not be the case. A study of training therapists found that more than half of novices were unhelpful to their patients. In this study by Wolfer and colleagues, the authors were interested in seeing if therapists at different stages of training had different levels of these important interpersonal skills. That is, do trainees as a higher level of training acquire more of these skills than those prior to receiving training. This was a small study comparing 19 therapists in clinical training versus 17 students in psychology but with no clinical training. Clinical trainees were in the program for at least 2 years, and received many hours of supervision. All participants watched a video recording of difficult patient statements. Participants’ reactions to the patient video were recorded and then trained raters coded the responses for level of interpersonal skills. Trainee therapists scored significantly higher than students on two scales of interpersonal skills, even after controlling for age. In fact, trainee therapists were over 13 times more likely to demonstrate facilitative interpersonal skills than untrained students. Although being in a clinical training program was associated with greater interpersonal skills, level of experience of clinical trainees (range 2 to 5 years of training) was not related to the level of interpersonal skills.
This is a relatively small study, so one should consider the findings quite cautiously. Nevertheless, it is one of the few studies to assess interpersonal skills in therapists. It is possible that only those with more interpersonal skills choose to be trained as clinicians – that is, only especially skilled students may go on to receive clinical training. However, the trainees’ substantial amount of clinical training (observing clinicians handle complex situations, receiving supervision to enhance self-reflection) may have facilitated growth in their interpersonal skills. As in previous research, clinical experience alone was not related to therapist interpersonal skill.
Supervision in Psychotherapy: The Impact of Attachment on Burnout
Hiebler-Rager, M., Nausner, L., Blaha, A., Grimmer, K., Korlath, S., Mernyi, M., & Unterrainer, H.F. (2020). The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2494.
Health professionals including psychotherapists are susceptible to burnout due to the emotional challenges of the work. There is some research indicating that with good supervision trainees and experienced therapists might be less susceptible to burnout (i.e., exhaustion, inefficiency, cynicism) and might gain a greater sense of personal coherence (i.e., that stressful events encountered in life are predictable and manageable, and that managing these events is personally meaningful). Supervision involves a senior qualified practitioner providing an intensive relationship-based education and training focused on supporting, guiding, and teaching a trainee or colleague. One can argue that the supervisory relationship provides the supervisee with a secure base from which to learn and grow as a professional. This secure base functions similar to an attachment relationship, which means that the bond, trust, agreement, and clarity of supervisory goals are key. That is, when a critical incident occurs in the therapy, the supervisee experiences stressful emotions and seeks support and security from the supervisor. One factor that may affect this process is the pre-existing level of attachment insecurity in the trainee (i.e., being too preoccupied with relationships or being too dismissing of relationships). Greater attachment insecurity may make it more difficult for supervisees to experience supervision as a safe environment. In this study, Hiebler-Rager and colleagues assessed if the quality of the supervisory relationship reported by supervisees predicted their level of burnout and of cohesion, and also if supervisees’ level of attachment insecurity also predicted these outcomes over and above the effects of supervision. The sample included 346 supervisees with a wide range of experience (0 to 50 years), ages (23 to 80 years), and professions who completed questionnaires about the supervisory relationship, attachment, burnout, and cohesion. Even after controlling for number of supervision sessions and supervisees’ clinical experience, lower quality of the supervisory relationship was related higher levels of burnout (β = −.31) and a lower sense of coherence (β = .31; both p < .01) in the supervisee. Higher levels of insecure attachment of the supervisee also predicted higher burnout (attachment anxiety: β = .30, p < .01) and lower coherence (attachment anxiety: β = −.40, p < .01; attachment avoidance:β = −.17, p < .01), even after controlling for the effects of number of supervisions sessions, experience, and the quality of the supervisory relationship. Adding attachment insecurity was associated with a medium to large incremental effect over and above the quality of the supervisory experience (R-square change = 0.13 for burnout, and 0.24 for coherence).
Supervision is a key manner in which psychotherapists are trained, and in which many participate in continuing education. A good quality supervisory relationship (secure and supportive) can help professionals mitigate the risk of burnout and to have a greater sense of personal coherence. However, some of the utility of supervision may depend to some extent on the supervisee’s own level of attachment insecurity. If a supervisee experiences an insecure attachment generally, they may require personal therapy to work on their sense of security in relationships and their ability to manage theirs and others’ emotions.
Why Does Where a Patient Lives Affect Their Outcomes in Psychotherapy?
Firth, N., Saxon, D., Stiles, W. B., & Barkham, M. (2019). Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology, 87(4), 345–356.
Patients vary in their outcomes from receiving psychotherapy. That is some patients receive more benefit than others or receive benefit more quickly than others. Previous research indicates that factors like higher symptom severity and socioeconomic deprivation are factors that lead to poorer outcomes. There is also evidence that some therapists are more effective than others so that 5% to 10% of patient outcomes depend on which therapist the patient sees. There is also research showing that the location of the clinic may reflect systematic differences in patient outcomes. This may be due to differences in clinic patient populations, to therapist recruiting practices, resource allocation, and accessibility. Research in population health suggest that local neighborhoods affect physical health. In this large study of over 26,000 patients receiving psychological therapy in the United Kingdom (UK) health system, Firth and colleagues estimated how much of patient outcomes were due to differences among patients, differences among therapists, and difference among clinics. Patients received person-centred, psychodynamic, cognitive-behavioral, or supportive therapies. Drop-out rates from therapy was 33%. Average age of patients was 38.4 years (SD = 12.94) and 69.3% were women. Most patients experienced anxiety (71.8%) and/or depression (54%). There were 462 therapists in the study working at 30 clinics throughout the UK. Up to 58.4% of patients who provided post-treatment data (i.e., completed therapy) showed reliable and clinically meaningful improvement, but there were large differences in patient improvement rates across the clinics (range: 23.4% to 75.2%) and across therapists (6.7% to 100%). Patient severity explained a large proportion of therapist differences. That is, whereas many therapists were effective with less severely symptomatic patients, relatively fewer therapists were effective with more severely symptomatic patients. Patient unemployment, location of the clinic in a more economically deprived area, and the proportion non-White patients in the area explained most of the differences between clinics. Patients who were employed and living in an economically advantaged neighborhood composed of mostly White residents had better outcomes.
We know from previous research that some therapists are more effective than others and these differences are more pronounced with more severely symptomatic patients. However, this study suggests that larger social factors like racism, systematic bias, and microaggressions also play a role in patient outcomes. Economic deprivation likely affects the level of funding and resources allocated to some clinics. Psychotherapists and funding sources need to take into account the broader socioeconomic, ethnic/racial, and geographic context in which the patient lives when planning and offering services to patients.